Tisotumab vedotin-tftv (Tivdak) (ARCHIVED)

Policy ID: I-246-005

Section: Injections

Effective Date: April 01, 2022

Revised Date: October 24, 2024

Revision Effective Date: December 08, 2024

Last Reviewed: November 19, 2024

Applies To: Commercial Only

**This policy has been Archived effective December 08, 2024. Click the Archive tab above for more information.**

Policy ID: I-246-005

Section: Injections

Effective Date: April 01, 2022

Revised Date: October 24, 2024

Revision Effective Date: December 08, 2024

Last Reviewed: November 19, 2024

Archived Date: December 08, 2024

Applies To: Commercial Only

Description

Tisotumab vedotin-tftv (Tivdak) is a tissue factor-directed antibody and microtubule inhibitor conjugate.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.

As treatment of individuals with recurrent or metastatic cervical cancer with disease progression on or after chemotherapy; or

Compendia Sources

Tisotumab vedotin-tftv (Tivdak) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations.

The use of tisotumab vedotin-tftv (Tivdak) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Code

J9273

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the United States Food and Drug Administration (U.S. FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

Diagnosis Codes

C53.0

C53.1

C53.8

C53.9

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-23-2022 - Effective April 01, 2022

Adopted new precertification drug policy

Internal Medical Policy Committee 3-23-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 7-26-2023 - Effective September 01, 2023

Updated order of the criteria, no clinical content change
Updated experimental/investigational statement

Internal Medical Policy Committee 7-16-2024 Effective September 01, 2024

Annual review no clinical content change

Internal Medical Policy Committee 11-19-2024 Effective December 08, 2024

Archived policy

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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